NUR301 EXAM 3 Practice questions

Which age-related change in musculoskeletal structure or function would alert the nurse to an increased risk of fracture? A. Kyphotic posture B. Cartilage thinning C. Decreased bone density D. Joint deformity

ANS: C Decreased bone density makes bone more porous and less stable.

Which of the following signs alerts the nurse to the possibility of carpal tunnel syndrome? A. A positive Trousseau's sign B. A positive Cullen's sign C. A positive Phalen's maneuver D. A positive Turner's sign

ANS: C Phalen's maneuver produces paresthesia in the median nerve within 60 seconds. Eighty percent of individuals with CST have a positive Phalen's maneuver result

the nurse provides diet education for a pt with chronic kidney disease. in order to decrease the BUN, which foods should be limited? a. protein like meat, beans, nuts eggs b. foods with high carbs and sugar c. foods with high potassium such as tomatoes and OJ D. foods with excessive sodium

.a. protein like meat, beans, nuts eggs rationale: kidneys are unable to excrete protein on their own pt should also limit potassium, but it does not affect BUN pt should also avoid sodium to prevent fluid retention

the nurse provides care for a client dx with a group A beta-hemolytic streptococcal bacterial infection. The nurse knows the client is at high risk to develop which condition? 1) myoglobinuria 2) acute glomerulonephritis 3) renal calculi 4) uremic encephalopathy

2) acute glomerulonephritis RATIONALE:: results from entrapment and collection of antigen antibody complexes. The immune complexes become lodged in the glomerular capillaries causing glomerular damage

A client is admitted to the emergency department after a motorcycle accident with a compound fracture of the left femur. Which action will be most essential for the nurse to take first? A. Check the dorsalis pedis pulses. B. Immobilize the left leg with a splint. C. Administer the prescribed analgesic. D. Place a dressing on the affected area.

A. The first action should be to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome (ACS), which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised.

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? Select all that apply. A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) C. Congestive heart failure D. Urinary tract infection (UTI) E. Osteomyelitis

A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) E. Osteomyelitis

The LPN tells the RN primary nurse the client diagnosed with liver failure is getting more confused. Which intervention should the RN implement first? A. Assess the client's neurological status. B. Notify the client's health-care provider. C. Request a STAT ammonia serum level. D. Tell the LPN to obtain the client's vital signs.

A. Assess the client's neurological status. Rationale: assess before ordering the stat ammonia level

When a physical assessment of gastrointestinal function is completed, which procedure follows inspection? A. Auscultation B. Percussion C. Light palpation D. Deep palpation

A. Auscultation rationale: The purpose of auscultation is to indi- rectly assess bowel sounds and vascular integrity of the arteries. In the assessment process, percussion and palpation usually occur prior to auscultation, but manipulation of the abdomen can result in inaccurate interpretation of bowel sounds as being hyperactive, so auscultation is completed prior to percussion and palpation.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? A. Balanced skin traction B. Buck's traction C. Overhead traction D. Plaster traction

A. Balanced skin traction is indicated for fracture of the femur or pelvis.

The client who is morbidly obese is 8 hours postoperative gastric bypass surgery. Which nursing intervention is of the greatest priority? A. Instruct the client to use the incentive spirometer. B. Weigh the client daily in the same clothes and at the same time. C. Apply sequential compression devices to the client's lower extremities. D. Assist the client to sit in the bedside chair.

A. Instruct the client to use the incentive spirometer. Rationale: oxygenation is priority over a dvt.

The older adult client has had a right open reduction internal fixation (ORIF) of a fractured hip. Which intervention will the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Reposition the client every 3 to 4 hours. C. Administer preventive pain medication during deep-breathing exercises. D. Prohibit the use of antiembolic stockings.

A. Keep the client's heels off the bed at all times. Rationale A. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. B. Repositioning the older adult client must be done every 2 hours to prevent skin breakdown and to inspect the skin for any signs of breakdown. C. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain on breathing. D. Antiembolic stockings are not contraindicated for older adults. They help prevent deep vein thrombosis.

The nurse is reviewing the HCP's orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first? A. Obtain the client's informed consent. B. Administer 2 mg of IV morphine, every 4 hours, PRN. C. Shave the lower right abdominal quadrant. D. Administer the on-call IVPB antibiotic.

A. Obtain the client's informed consent.

The nurse has received the a.m. shift report. Which client should the nurse assess first? A. The client diagnosed with peptic ulcer disease who is reporting acute epigastric pain B. The client diagnosed with acute gastroenteritis who is upset and wants to go home C. The client diagnosed with inflammatory bowel disease who is receiving total parenteral nutrition D. The client diagnosed with hepatitis B who is uncomfortable, jaundiced, and anorexic

A. The client diagnosed with peptic ulcer disease who is reporting acute epigastric pain Rationale: those are normal signs for hepatitis B. acute pain is not normal for peptic ulcer disease they could have GI bleeding.

The patient with clinical manifestations of oliguria and elevated creatinine clearance would be most consistent with: A. Tubular necrosis B. Tubular secretion C. Glomerular filtration D. Capillary permeability

A. Tubular necrosis

What information should be elicited from the client before the client undergoes an arthrography? A. Allergy to shellfish or iodine B. Onset of symptoms C. Recent upper respiratory infection D. Time since the last meal was ingested

ANS: A Clients with shellfish or iodine allergies often have severe allergic reactions to the standard dyes used during arthrography.

Which clinical manifestation would serve to alert the nurse that a client's osteomyelitis is chronic, rather than acute? A. Ulceration of the skin B. Temperature more than 101° F (38° C) C. Erythema of the affected area D. Swelling around the affected area

ANS: A Fever, swelling, and erythema are far less common in chronic osteomyelitis, whereas ulceration, sinus tract formation, and localized pain are more characteristic.

A client has just undergone an arthrography of the right knee and is preparing to be discharged home. What statement made by the client indicates a need for further postprocedure teaching? A. "I will be able to resume my normal physical activity in a few hours." B. "I will apply ice to my right knee to decrease swelling." C. "I will keep my right knee wrapped until tomorrow. "D. "I will rest my right knee for the next 12 to 24 hours."

ANS: A Following an arthrography, the client's knee may be wrapped and ice may be applied to reduce swelling. Physical activity is restricted for 12 to 24 hours following the test.

In the client with hypocalcemia, what is the response of the parathyroid hormone, PTH? A. It reduces the excretion of calcium. B. It blocks the renal excretion of calcium. C. It stops bone from stimulating osteoclastic activity. D. Its secretion diminishes to preserve the bone calcium supply.

ANS: A In the presence of hypocalcemia, PTH secretion increases, which stimulates bone to promote orthoclastic activity, adding more calcium to the blood. PTH also reduces the renal excretion of calcium.

What maneuver should the nurse ask the client with carpal tunnel syndrome to perform to assess for early motor changes? A. Ask the client to pick up a coin. B. Ask the client to grasp his or her hand .C. Ask the client to pick up a 5-pound weight .D. Ask the client to place the backs of the hands together and flex the wrists.

ANS: A Motor changes begin with a weak pinch and progress to muscle weakness and wasting. Asking the client to pick up a coin is an example of testing the ability to pinch.

Which of the following diagnostic procedures can determine whether a bone tumor is benign or malignant? A. Bone scan B. Bone biopsy C. Computed tomography D. Magnetic resonance imaging

ANS: B Although different types of imaging can provide information associated with benign or malignant bone tumors, only a biopsy can confirm the tumor type.

A client is about to begin drug therapy for osteomyelitis. What information regarding this treatment would be most appropriate for the nurse to provide to the client? A. "You will need to remain in the hospital for the duration of the treatment. "B. "You will need to undergo treatment with IV antibiotics for several weeks." C. "Only close family members may be permitted to visit while you are receiving treatment." D. "Once the IV medications are completed, the infection is considered cured, and no further treatment is needed."

ANS: B Typically, osteomyelitis requires treatment with IV antibiotics for several weeks. The client will leave the hospital with a central IV catheter for home infusion of the medication. Oral antibiotics for several more weeks usually follow the IV regimen.

Which occupation would increase a client's risk for carpal tunnel syndrome? A. Sales clerk B. House painter C. Baseball pitcher D. Computer programmer

ANS: D In the presence of hypocalcemia, PTH secretion increases and stimulates bone to promote orthoclastic activity, adding more calcium to the blood. PTH also reduces renal excretion of calcium

Which precautions or instructions should be provided to the client who is scheduled to have a bone scan? A. "Do not eat or drink for 12 hours before the procedure." B. "Avoid eating any type of shellfish." C. "Avoid coming within 10 feet of other people or pets until the radioactivity clears." D. "Increase your fluid intake to at least 3000 mL after the test to help clear the radioisotope."

ANS: D The amount of radioactivity in the isotope is minimal and poses no hazard to the client or the client's contacts. Increasing fluid intake helps urine clearance of the isotope.

The nurse has received the following providerorders for Mr. Jones, who was recently admittedto the medical unit with complaints of recent weight increases, swelling in his hands and feet, voiding only small amounts of urine, and fatigue. He was diagnosed with renal insufficiency and uncontrolled hypertension. Which order should the nurse plan to implement first? A. Administer 40 mg furosemide (Lasix) IV daily. B. Implement fluid restriction less than1,500 mL/24 hr. C. Monitor urine specific gravity with each void. D. Instruct the patient to follow low-sodium diet.

Answer: A Rationale: Although each of the provider ordersare appropriate for Mr. Jones, administering thediuretic Lasix is of highest priority to promotedincreased excretion of potassium and fluid in order to lower the blood pressure, heart rate, and decrease peripheral edema. The remaining provider orders should be implemented following the administration of Lasix.

The patient with which condition is at the highest risk for fistula formations? A. Crohn's disease B. Ulcerative colitis C. Diverticulitis D. Irritable bowel disease

Answer: A Rationale: Because Crohn's disease is transmural, affecting all layers of the bowel, it can develop sinus tracts leading to fistula formation.

What clinical manifestation is consistent with a diagnosis of liver failure? A. Yellow sclera B. Arm and leg scars from IV drug abuse C. Tachycardia D. High blood pressure

Answer: A Rationale: Yellowing of the sclera is a classic sign of liver failure. Scarring from IV drug abuse could be a risk factor but not a means of diagnosis. Tachycardia and high blood pressure can have several clinical manifestations that may not be consistent with liver failure.

The liver receives deoxygenated blood from the: A. Portal vein B. Gastric artery C. Hepatic artery D. Hepatorenal vein

Answer: A The portal vein carries deoxygenated nutrient-rich blood from the small intestines, and the hepatic artery delivers oxygen-rich blood from the general circulation.

Which subjective and objective data support the order for fecal occult blood testing? (Select all that apply.) A. Reports of stool darker than usual B. Reports of feeling tired and complaints of light- headedness when moving from a sitting to a standing position C. Plavix (clopidogrel) 75 mg PO daily D. Skin warm, dry, flaky, and intact E. Heart rate 115 bpm, R 18, Lying BP 130/80 mm Hg, Standing 100/60 mm Hg

Answer: A, B, C, and ERationale: A: Could be an indicator of GI bleed. B: Could be an indicator of volume loss. C: This drug can cause GI bleeding. E: Could be an indica- tor of volume loss.

The function of the liver includes which of the following? (Select all that apply.) A. Metabolism of proteins B. Production and secretion of bile salts C. Production of vitamins A B D E K D. Filters blood of toxins E. Production of red blood cells

Answer: A, B, and D Major functions of the liver include 1) absorption and metabolism of nutrients; 2) degradation of toxins, hormones, and medications; and 3) synthesis of proteins (clotting factors, albumin, several clotting factors, fibrinogen, and prothrombin). Other cells known as Kupffer cells are responsible for detoxifying the blood of bacteria. The branches of the hepatic artery and portal veins supply a mixture of oxygen and nutrient-rich blood to the hepatocytes. In terms of the digestive process, the liver aids in the digestion of fat by producing bile acids and lecithin.

A patient with liver disease is being evaluated for varices. The nurse prepares the patient for which procedure? A. Liver biopsy B. EGD C. ERCP D. TIPS

Answer: B Rationale: An EGD is a diagnostic procedure where an endoscope is placed through the patient's mouth into the GI tract to visualize upper GI bleeding caused by esophageal varices. While the other procedures listed are oftentimes used in patients with liver failure, they are not used to evaluate varices.

Which clinical manifestation experienced by Mr. Green will be relieved by paracentesis? A. Jaundice B. Dyspnea C. Diarrhea D. Decreased urine output

Answer: B Rationale: Paracentesis involves draining of accumulated ascites in the peritoneum which can push up on the diaphragm causing shortness of breath. restrict sodium

In a patient with cirrhosis, the nursing diagnosis "risk for injury and bleeding related to prolonged clotting factors" is most appropriate related to which disorder? A. Pruritus B. Vitamin K deficiency C. Hyponatremia D. Ascites

Answer: B Rationale: Patients with cirrhosis have a decrease in the synthesis of bile salts. The liver makes clotting factors which rely on the presence of vitamin K to function normally. Vitamin K is a fat soluble vitamin that requires bile salts to be absorbed properly. In cirrhosis there is a decrease in the bile salts and decreased ability to absorb vitamin K.

Which information does the nurse include in teaching to the patient about his new diagnosis of liver failure? A. "Avoid foods high in fat" B. "Avoid foods high in protein" C. "Need for oxygen when he is discharged" D. "Need for antihypertensive medications

Answer: B Rationale: Patients with liver failure should eat a balanced diet. Too much protein in the diet will result in an increased amount of ammonia in the blood. In liver failure the liver is unable to process this ammonia and can lead to changes in mental status.

Which information does the nurse include in the teaching to Jack related to his diagnosis of ulcerative colitis? A. "Decrease fluid intake to decrease diarrhea." B. "Spread out your meals to six times per day." C. "Avoid foods high in potassium." D. "Increase your intake of simple sugars for energy."

Answer: B Rationale: The patient is encouraged to eat small, frequent meals in order to decrease gastric motility and decrease diarrhea. The patient is at risk for fluid volume deficit, so fluids are not decreased. Loss of potassium may be increased with diarrhea and may require supplementation. Simple sugars increase gastric motility and can exacerbate diarrhea.

Of the following three patients, which one would the nurse see first? A. A 42-year-old male arrived to the floor four hours ago after a liver biopsy. The patient called, and you are at the nurses station and answer the call bell. The patient has some visitors and reports that he just returned to the bed from the bathroom and is complaining of pain at the biopsy site, but you hear them laughing and talking in the room. You know the patient just received pain medicine upon arrival to the floor. B. A 65-year-old male with a history of cirrhosis arrived to the floor an hour ago from the emergency department with shortness of breath and jaundice. You have been busy and have not seen this patient yet. His heart rate is 110, blood pressure is 90/50, and respiratory rate 32. He received diuretics in the emergency department and is scheduled for a paracentesis in the next few hours. C. 24-year-old female IV substance abuser who was hit in the abdomen with a baseball bat and is being observed for abdominal trauma, specifically liver contusions. Her heart rate is 100, has mild pain in the abdomen, and denies nausea. She arrived to the floor 30 minutes ago and you have not seen her yet, but your colleague admittedthe patient to the room and told you she was tachycardic but stable.

Answer: B Rationale: The priority patient should be the 65-year- old who was recently given diuretics for fluid overload so that you can obtain a repeat set of vital signs. The patient has an elevated heart rate and is hypotensive. It is necessary to determine if the diuretics will impact thevital signs further and to determine if the patient has had a response the medication. You should be con- cerned that the pain the liver biopsy patient may indi- cate bleeding from the procedure over four hours ago. The trauma patient is the most stable.

The liver receives what percentage of cardiac output? A. 10% B. 25% C. 40% D. 50%

Answer: B The liver is located under the diaphragm in the right upper quadrant (RUQ) of the abdominal cavity and receives approximately 25% of the cardiac output via the hepatic portal vein and the hepatic artery.

Where is the primary location of nutrient absorption in the gastrointestinal system? A. Stomach B. Small intestine C. Large intestine D. Pancreas

Answer: B The small intestine's primary function is digestion and absorption of nutrients across the intestinal wall into the circulation.

In assessing the patient with an ileostomy, the nurse focuses on which "three Ss"? (Select all that apply.) A. Sensation B. Skin C. Stoma D. Stool E. Size

Answer: B, C, and D: skin, stoma, stool Rationale: The assessment of a stoma includes the surrounding skins that should be consistent with the rest of the abdomen. The stoma itself should be pink and moist. The consistency of the stool is dependent upon the area of the stoma, and in the patient with an ileostomy, the stool is semi-liquid.

An 80-year-old male presents for a physical examination and reports changes in his urinary patternincluding urinary frequency, hesitancy, and a slowstream of urine. As the nurse, you recognize thesefindings are likely attributed to which of thefollowing? A. Decreased bladder capacity related to age B. Renal failure C. Enlargement of the prostate gland D. Decrease in size of the kidneys

Answer: C Rationale: A majority of males experience enlargement of the prostate gland, usually benign, with increasing age. This results in compression of the urethra and can explain subjective findings such as urinary frequency, hesitancy, straining upon urination, and a slow stream of urine. Although the bladder capacity and size of the kidneys decrease with age, these do not explain this patient's subjective reports. In cases of renal failure, the amount and frequency of urine typically decreases.

The nurse includes which information in the teaching plan about management of PKD? A. "Your blood pressure will normalize when we successfully manage your PKD." B. "Your UTI will not recur if you finish your antibiotic prescription." C. "Staying on your antihypertensive medication is necessary to control your blood pressure." D. "This disease is reversible if you closely follow your provider's orders."

Answer: C Rationale: BP and UTI are chronic problems with PKD. Continued BP medication will be necessary. PKD is not reversible.

A patient presents to the ED with complaints of abdominal pain and watery, bloody stools. What diagnostic tests does the nurse expect to be ordered on the basis of these symptoms? A. CBC, MRI, electrolytes, stool analysis B. CT scan, MRI, chemistry panel, ERCP C. Colonoscopy, CBC, wireless capsule endoscopy, upper GI endoscopy D. BUN, creatinine, ultrasound, chest x-ray

Answer: C Rationale: Bloody stools are more common with ulcerative colitis. Therefore a CBC should be ordered. Wireless capsule endoscopy evaluates the portion between what can be seen with upper GI endoscopy and the colonoscopy. Ulcerative colitis affects only the large intestine but Crohn's disease affects anywhere from mouth to anus and must be ruled out before a surgical decision can be made. Blood, mucus, and pus are common with ulcerative colitis but not with Crohn's.

The nurse caring for Ms. Flood incorporates which priority nursing diagnosis into the plan of care related to her diagnosis of PKD? A. Pain related to irritation on urination secondary to UTI B. Imbalanced nutrition related to excessive loss of protein in the urine C. Decreased cardiac output related to dysrhythmias secondary to electrolyte imbalance D. Impaired perfusion related to decreased circulating volume secondary to diuresis

Answer: C Rationale: Decreased cardiac output is a risk due to the potential risk electrolyte imbalances that occur with renal failure.

Elevated ammonia levels can lead to hepatic encephalopathy. Which provider order best reduces this risk in patients with cirrhosis? A. Administer furosemide and spironolactone. B. Administer antibiotics. C. Restrict protein intake. D. Restrict caloric intake.

Answer: C Rationale: Encephalopathy is caused by accumulation of toxins in the liver, one of which is ammonia. Ammo- nia is produced when proteins are broken down by the body. In a patient with cirrhosis the liver is not able to clear this toxin from the body; thus, it is important to restrict protein intake.

The nurse includes which dietary information in the teaching plan about the management of chronic kidney disease? A. Decrease fluid intake and protein intake, decrease carbohydrate intake B. Increase fluid intake, decrease carbohydrate intake and protein intake C. Decrease fluid intake and protein intake, increase carbohydrate intake D. Increase fluid intake, increase carbohydrate intake and protein intake

Answer: C Rationale: It is important to decrease fluid intakebecause people with CKD may have a reduction inurine output, causing fluid to build up in the body; this puts the patient at further risk for volume overload. Decreasing protein intake will limitthe buildup of waste products in the body, and increasing carbohydrates will provide patients with a good source of energy that is lost with the low-protein diet.

The nurse monitors for which clinical manifestation in Ms. Flood, who is newly diagnosed with PKD? A. Hypotension related to fluid shifts B. Bradycardia related to fluid overload C. Hypertension related to decreased renal perfusion D. Tachycardia related to fluid loss

Answer: C Rationale: Newly diagnosed PKD typically presents with hypertension. Fluid overload and fluid shifts occur later in the disease if renal failure occurs.

In reviewing diagnostic results of a patient with suspected hepatitis, the nurse correlates which result as consistent with hepatitis A? A. Prolonged prothrombin time (PT) B. Decreased white blood cell count C. Presence of IgM anti-HAV D. Detectable serum HBV DNA

Answer: C Rationale: The most definitive diagnosis of Hepatitis A is through a blood test for the presence of antihepatitis A immunoglobulin M (IgM anti-HAV). Acute hepatitis B occurs after an incubation period of 4 to 10 weeks, and chronic hepatitis B is diagnosed by detectable serum HBV-DNA levels and persistent elevation of ALT and AST levels.

Reabsorption of the majority of the water from the gastrointestinal tract occurs in the: A. Liver B. Small intestine C. Large intestine D. Rectum

Answer: C The large intestine's primary function is absorption of water. There is also some absorption of electrolytes although not to the extent of absorption in the small intestine.

What is the most distal section of the small intestine? A. Cecum B. Duodenum C. Ileum D. Jejunum

Answer: CThere are three sections to the small intestine: • Duodenum—attaches to the pylorus and is approximately 10 in. (25 cm) long • Jejunum—approximately 8 ft (2.5 m) • Ileum—approximately 12 ft (3.5 m)

The nurse caring for a patient with liver failure notes a change in mental status and elevated ammonia level. Which ordered interventionsare most directly related to treating these clinical manifestations? A. Diuretics B. High-protein diet C. Coumadin D. Lactulose and neomycin

Answer: D Rationale: Interventions to decrease the build up of ammonia in the body include laxatives and antibiotic therapy. The antibiotic neomycin helps decrease the amount of bacteria, and the laxative helps remove the toxins from the body. Protein restricted diets are important with liver failure; diuretics are used in liver failure for fluid overload, not increased ammonia levels; and Coumadin is a blood thinning agent, not utilized in a patient for elevated ammonia levels.

The nurse providing care for Ms. Flood, who is diagnosed with PKD, should include which activity into the plan of care? A. Providing cranberry juice at meals to reduce the risk of UTIs B. Frequent range-of-motion exercises to reduce stiffness due to inactivity C. Encourage fluids to maintain adequate volume and perfusion to the kidneys D. Restrict fluids to reduce the risk of fluid overload

Answer: D Rationale: Fluid overload is a chronic problem due to renal failure requiring a fluid restriction.

The nurse is caring for a patient who has had surgery for colon cancer and has a permanent colostomy. Which assessment must the nurse report to the provider immediately? A. The stoma is reddish pink and moist. B. The stoma is flat against the skin. C. The stoma has not expelled any flatus or stool in the first 24 hours. D. The stoma is dark and bluish in appearance.

Answer: D Rationale: If the stoma begins to show signs of ischemia (dark red, purplish, or black color) or unusual bleeding, the physician should be notified immediately. This is a sign that there is little or no blood flow to the stoma.

The RN staff nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which tasks should the RN assign to the UAP? Select all that apply. A. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia. B. Request the UAP change the linens for the 89-year-old client diagnosed with fecal incontinence. C. Tell the UAP to assist the 54-year-old client with a bowel management program. D. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis. E. Direct the UAP to apply compression stockings to the 64-year-old client who had abdominal surgery.

B. Request the UAP change the linens for the 89-year-old client diagnosed with fecal incontinence. C. Tell the UAP to assist the 54-year-old client with a bowel management program. D. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis. E. Direct the UAP to apply compression stockings to the 64-year-old client who had abdominal surgery.

The client has a grade III compound fracture of the right tibia. To prevent infection, which intervention will the nurse implement? A. Applying Neosporin (bacitracin, neomycin, and polymyxin B) ointment to the site daily with a sterile cotton-tipped swab B. Using strict aseptic technique when cleaning the site C. Leaving the site open to the air to keep it dry D. Assisting the client to shower daily and pat the wound site dry

B. Using strict aseptic technique when cleaning the site Rationale A. Chlorhexidine (Hexicleans), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. B. Using aseptic technique is the best way to prevent infection. C. A wound of this type should be kept covered. D. The wound site of a compound fracture must not be exposed to a shower. This practice violates maintaining aseptic technique.

the nurse understands that chronic kidney disease is defined by which of the following a. a rapid decrease in urine output with an elevated BUN B. progressive, irreversible damage to kidneys c. abruprupt increase in creatinine clearance with a decrease in urinary output d. confusion leading to coma and death

B. progressive, irreversible damage to kidneys

the nurse provides care for a pt reporting sudden onset of severe right flank pain. the pt is diagnosed with urinary calculi. which nursing action has immediate priority a. ensure pt is NPO B. relieve pain c. strain urine d. obtain a mid stream urine specimen

B. relieve pain rationale: pt will have severe pain increase fluid intake to promote passage of the stone urine should be strained to collect calculi a urine specimen will be obtained if infection is suspected

the nurse providing care for the pt post motor vehicle accident with a suspected injury to the renal system anticipates which of the following orders a. an ECG B. urinalysis c. administer diuretics d. administer antihypertensives

B. urinalysis

A patient has been admitted to the critical care unit from the subacute medical unit because his signs and symptoms of liver failure have become more pronounced over the past 24 hours. The critical care nurse who is planning this patient's care should prioritize which of the following nursing diagnoses? A) Knowledge deficit related to the causes of liver failure B) Bowel incontinence related to treatments for liver failure C) Risk for bleeding related to complications of liver failure D) Ineffective coping related to complications of liver failure

C) Risk for bleeding related to complications of liver failure Rationale: liver failure: bleeding is priority

The unlicensed assistive personnel (UAP) tells the RN a client, who had a laparoscopic cholecystectomy, is reporting abdominal pain. Which intervention should the RN implement first? A. Check the medication administration record for the last pain medication the client received. B. Instruct the UAP to ask the client to rate her pain on a 1 to 10 pain scale. C. Assess the client to rule out any postoperative surgical complications. D. Tell the UAP to obtain the client's vital signs and pulse oximeter reading.

C. Assess the client to rule out any postoperative surgical complications.

The client who has had abdominal surgery is reporting pain and tells the nurse, "I felt something pop in my stomach." Which intervention should the nurse implement first? A. Check the client's apical pulse and blood pressure. B. Determine the client's pain on a 1 to 10 pain scale. C. Assess the client's surgical wound site. D. Administer pain medication intravenously.

C. Assess the client's surgical wound site. Rationale: first assess the pt to see if the incision opened up

Patients experiencing diarrhea are at risk for which alteration in absorption? A. Decreased chyme absorption B. Increased chyme absorption C. Decreased potassium absorption D. Increased potassium absorption

C. Decreased potassium absorption Rationale: The function of the large intestine is fluid and electrolyte reabsorption and elimination.

The nurse is concerned that a client who had an open reduction, internal fixation of his tibia and fibula is at risk for complex regional pain syndrome. What assessment findings at the affected area are common when a client has this complication? Select all that apply. A. Dull, aching pain B. Decrease in sweating C. Muscle spasms D. Skin discoloration E. Paresis F. Edema

C. Muscle spasms D. Skin discoloration E. Paresis F. Edema Rationale Muscle spasms, skin discoloration, paresis, and edema are all manifestations that present in complex regional pain syndrome. The client experiencing this syndrome would have intense, unrelenting, burning pain rather than dull, aching pain, as well as excessive (not decreased) sweating due to dysfunction of the autonomic nervous system.

The client is experiencing severe diarrhea and has a serum potassium level of 3.3 mEq/L. Which intervention should the nurse implement first? A. Notify the client's health-care provider. B. Assess the client for leg cramps. C. Place the client on cardiac telemetry. D. Prepare to administer intravenous potassium

C. Place the client on cardiac telemetry. Rationale: potassium cardiac is always priority

Which laboratory value below would be associated with the patient experiencing dehydration? A. Presence of casts B. WBCs C. Specific gravity 1.035 D. Presence of nitrates

C. Specific gravity 1.035

Which task would be most appropriate for the RN staff nurse on the GI unit to delegate to the unlicensed assistive personnel (UAP)? A. Request the UAP to draw the serum liver function test. B. Ask the UAP to remove the nasogastric tube. C. Tell the UAP to empty the client's colostomy bag. D. Instruct the UAP to enter HCP orders into the EHR

C. Tell the UAP to empty the client's colostomy bag. Rationale: uap cant do serum live test or remove NG tube and cant enter orders but they can empty colostomy bags

Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the RN staff nurse? A. The UAP is refusing to feed the client diagnosed with acute diverticulitis. B. The UAP would not place the client who was on bedrest on the bedside commode. C. The UAP placed the client with a continuous feeding tube in the supine position. D. The UAP placed sequential compression devices on the client who is on strict bedrest.

C. The UAP placed the client with a continuous feeding tube in the supine position. Rationale: tube feeding should never be flat bc risk of aspiration

The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first? A. The client who is 6 hours postoperative small bowel resection who has hypoactive bowel sounds in all four quadrants B. The client who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset C. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen D. The client who is 2 days postoperative for an emergency appendectomy and is reporting abdominal pain, rating it as an 8 on a pain scale of 1 to 10

C. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen Rationale: hypoactive bowel sounds is normal. Rigid, hard abdomen means a major complication like a perforation. You would assess D second

The client is diagnosed with esophageal bleeding. Which assessment data warrants immediate intervention by the nurse? A. The client's hemoglobin/hematocrit is 12.4/39. B. The client's abdomen is soft to touch and nontender. C. The client's vital signs are T 99, AP 114, RR 18, BP 88/60. D. The client's nasogastric tube has coffee ground drainage.

C. The client's vital signs are T 99, AP 114, RR 18, BP 88/60. Rationale: we already know pt has an esophageal bleed so coffee ground is normal. The VS are abnormal so C

an older adult is diagnosed with a fractured femur. which is an early sign of a fat embolism a. chest pain and dyspnea b. increased RR, P, T C. altered mental status d. petechiae

C. altered mental status rationale: earliest sign of fat embolism is alteration in mental status due to low arterial oxygen level occurs within 48 hours after the fracture an increase in VS, chest pain, dyspnea, and petechiae occur later

The day after an appendectomy, the pt has severe abd pain, a temperature of 101, and a rigid abdomen. The nurse suspects which complication a. A: anesthesia intolerance. B: atelectasis and pneumonia C: infection of peritoneal sac D: bladder distention

C: infection of peritoneal sac : can be caused by ruptured appendix or gross contamination of peritoneum. s/s of peritonitis include severe abd pain, abd rigidity, decreased bowel sounds, n/v, elevated temperature and shock

The client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? A. "Simple fracture involves a break in the bone, with skin contusions." B. "Compound fracture does not extend through the skin." C. "Simple fracture is accompanied by damage to the blood vessels." D. "Compound fracture, grade I, involves minimal skin damage."

D. "Compound fracture, grade I, involves minimal skin damage."

The nurse prepares to perform a neurovascular assessment on the client with closed multiple fractures of the right humerus. Which technique will the nurse use? A. Inspect the abdomen for tenderness and bowel sounds. B. Auscultate lung sounds. C. Assess the level of consciousness and ability to follow commands. D. Assess sensation of the right upper extremity.

D. Assess sensation of the right upper extremity.

The nurse monitors for which complication in the patient who has undergone a barium enema? A. Fluid overload B. Dehydration C. Diarrhea D. Constipation

D. Constipation Rationale: When the barium is not properly eliminated, it can harden and cause constipation.

The client is admitted to the hospital with a diagnosis of acute kidney injury. The nurse understands which explanation is the MOST accurate description of the client's condition? a) A sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage b) A progressive deterioration in kidney function that ends fatally when uremia develops c) An inflammation of the kidney pelvis, tubules, and interstitial tissues of one or both kidneys d) An inflammation process precipitated by chemical changes in the glomeruli of both kidneys

a) A sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage RATIONALE:acute kidney injury is sudden cessation of kidney function caused by renal failure or by glomerular or tubular damage

An older male patient complains to the physician of urinary frequency, urgency, and dysuria. A cystoscopy is performed. After the cystoscopy, which of the following nursing actions has the highest priority? a) Obtain the patient's vital signs: b) Report any nausea to the physician c) Review the patient's written discharge instructions d) Administer a sedative

a) Obtain the patient's vital signs rationale: assess for bleeding and infection. Monitor urine volume and color should be pink tinged. Abnormal pelvic pain indicates trauma. -notify if blood clots or urinary output decreases -sedative given before procedure

the nurse obtains a history from a client suspected of having a duodenal ulcer. the nurse expects the client to make which statement i have been vomiting bright red blood a. "I have abdominal pain and tenderness." b. "I have been vomiting bright red blood." c. "I have frequent loose stools every day." d. "I have increased pain after eating."a

a, "I have abdominal pain and tenderness.": epigastric pain occurs 2-3 hours after eating is most common symptom and food relieves the pain "I have been vomiting bright red blood.": melena is more common with duodenal ulcer and hematemesis is common with gastric ulcer "I have frequent loose stools every day.": diarrhea is a symptom of ulcerative colitis and not associated with ulcers "I have increased pain after eating.": increased pain is gastric ulcer and the pain is relieved by vomiting

The nurse cares for a client after a traditional cholecystectomy. The nurse contacts the health care provider if which observation is made? a. 800 mL bloody drainage the first day postop b. The client frequently reports abdominal pain during the first 24 hours. c. Nasogastric tube connected to intermittent suction the first day postop d. Temperature elevation to 100F (37.8C) the evening of surgery

a. 800 mL bloody drainage the first day postop RATIONALE: 50 ml is an appropriate amount of drainage. Too much drainage indicates hemorrhage b. The client frequently reports abdominal pain during the first 24 hours. : incisional pain is common and treated with morphine using a patient controlled pump c. Nasogastric tube connected to intermittent suction the first day postop: decompress stomach, tube removed when peristalsis returns d. Temperature elevation to 100F (37.8C) the evening of surgery: not unusual to have a slightly elevated temperature evening of surgery

The nurse cares for the client admitted with the diagnosis of small bowel obstruction who has severe abdominal distension. Which finding best describes the reason for the distension? a. Accumulation of fluid in the intestine b. Increased gastric acid ph levels c. Vagal nerve stimulation d. Decreased perfusion of intestine

a. Accumulation of fluid in the intestine rationale:intestinal obstruction prevents flow of contents through the intestinal lumen. Fluid moves into intestinal lumen causing the abd distention Increased gastric acid ph levels: this will increase abd distention, but accumulation of gastric juice is not significant as fluid Vagal nerve stimulation: increases GI motility Decreased perfusion of intestine: causes ischemia and necrosis of the intestine

Which abnormal laboratory value associated with cirrhosis is correct? Select all that apply. a. Albumin level is decreased b. Decreased ammonia c. Decreased prothrombin time d. Decreased bilirubin

a. Albumin level is decreased

The nurse instructs the family of the client diagnosed with hepatitis A how to prevent the spread of the disease. It is most important for the nurse to include which instruction? a. Family should use separate utensils and drinking glasses b. Family must avoid contact with blood c. family can not donate blood during next year: d. Family with no signs or symptoms are not infected

a. Family should use separate utensils and drinking glasses rationale : pt should wash hands before eating and after using the toilet and all glasses or utensils should be separate Family must avoid contact with blood: hepatitis B and C are blood borne viruses Family can not donate blood during next year: family can but the pt with hepatitis cannot for at least 12 months Family with no signs or symptoms are not infected: pt with HAV are most infectious before onset of symptoms

the clinic nurse monitors a client recovering from hepatitis a. the nurse knows that this is transmitted through which route? a. fecal oral b. droplet c. airborne d. contact

a. Fecal oral: this is true. Due to consumption of contaminated food or water Droplet: this is for influenza Airborne: this is for chickenpox Contact: this is conjunctivitis

the nurse provides care for a client diagnosed with a peptic ulcer. which nursing action is most appropriate a. Identify stress factors for pt b. Avoid giving pt choices c. Encourage pt to be angry d. Avoid discussing the pt's symptoms

a. Identify stress factors for pt

Older client says "I have indigestion and have been taking over the counter cimetidine for 3 weeks, what comment requires immediate follow up? a. My child tells me that I seem to be confused b. I should have consulted my doctor before taking this medication c. I don't have heartburn since i started taking this medication d. I take cimetidine at the same time i take antacids

a. My child tells me that I seem to be confused rationale:large doses of cimetidine can cause confusion in older adults. This requires immediate followup by the nurse. Monitor VS, liver enzymes, and blood counts I should have consulted my doctor before taking this medication: a pt should not take cimetidine for over 2 weeks without talking to their doctor I don't have heartburn since i started taking this medication: cimetidine is used to treat duodenal ulcers and benign gastric ulcers and to treat GERD I take cimetidine at the same time i take antacids: instruct pt to not take antacids within 30-60 minutes of taking cimetidine

the nurse is caring for a patient with a peptic ulcer. Which symptom would suggest that it is in the duodenum? a. Pain occurs 2-3 hours after meals b. Pain may be relieved by vomiting c. Ingestion of food does not help with the pain d. Vomiting is a common occurrence

a. Pain occurs 2-3 hours after meals

Nurse prepares a pt for a total hip replacement. What info will likely postpone the surgery? a. Pt reports burning on urination b. Pt's hemoglobin is 15 c. Pt reports heartburn d. Pt's platelet count is 250,000

a. Pt reports burning on urination rationale: this indicates a UTI and is a contraindication to a total joint placement b. Pt's hemoglobin is 15: within normal range c. Pt reports heartburn: would not postpone surgery d. Pt's platelet count is 250,000: this is normal

The nurse provides care for a pt with acute pancreatitis. The nurse administers morphine IV for pain. Which behavior indicates the medication is effective? a. Pt sleeps for one hour B: pt frequently changes position in bed C: pt states there is less nausea D: pt does not report thirst

a. Pt sleeps for one hour: pt sleeping indicates morphine is effective. Nurse can evaluate the pain on a scale before and after administration

Nurse evaluates care given to a pt after a left below the knee amputation. Nurse should intervene if the following is observed? a. The dressing id dated 2 days prior b. Surgical tourniquet readily available c. Nurse uses a transfer belt when pt transfers from bed to chair d. Pt sits in a chair frequently for short periods of time

a. The dressing id dated 2 days prior rationale:dressing changes need to occur at least every 24 hours Surgical tourniquet readily available: if excessive bleeding occurs, apply tourniquet and call the surgeon asap Nurse uses a transfer belt when pt transfers from bed to chair: accurate, also pt should be wearing a non skid sole shoe and be stabilized Pt sits in a chair frequently for short periods of time: to prevent flexion contractures of the hip, pt should not sit for long periods of time

Total hip arthroplasty is scheduled for a pt w/a degenerative joint disease of left femoral head. It is MOST important for a nurse to place pt's left leg in which of the following positions? a. abducted w/toes pointing upward b. elevated on two pillows w/knees flexed c. elevated on several pillows w/ankle abducted d. adducted w/ankle joint hyperextended

a. abducted w/toes pointing upward rationale: : Major complication of hip replacement is dislocation of prosthesis; maintain abduction by placing pillow between legs; do not stoop or cross legs

a pt has a gastroscopy performed and a gastric aspirate is taken for analysis. the nurse understands the purpose of a gastric aspirate is which reason a. assess acid secretion and bacteria b. inhibit acid secretion c. assess mucus d. introduce gastric irritating substances

a. assess acid secretion and bacteria

the nurse is caring for a pt receiving IV contrast for a renal CT scan. nursing responsibilities include which of the following? select all that apply a. assess for allergies to contrast, iodine, and seafood b. educate pt to increase fluid intake after the study c. obtain an order for NPO after the study d. ensure IV contrast is only administered through central line e. assess baseline creatinine value prior the study

a. assess for allergies to contrast, iodine, and seafood b. educate pt to increase fluid intake after the study e. assess baseline creatinine value prior the study

the nurse includes teaching for a pt who has undergone a laparoscopic cholecystectomy prior to discharge. the nurse should include which instruction a. begin light exercise immediately b. limit diet to liquid and soft food for 3 days c. contact doctor if pain in right shoulder d. remove adhesive strips over puncture wounds in 5 days

a. begin light exercise immediately rationale: may begin walking immediately, avoid lifting heavy objects for 1 weeks gradually add fat to diet

the nurse expects to see which lab value in the pt with renal failure a. decreased calcium b. increased calcium c, decreased phosphorous d. increased hematocrit

a. decreased calcium

the nurse instructs the pt with a sigmoid colostomy how to irrigate the colostomy. which action does the nurse include in the teaching a. dilate the stomach gently with gloved finger b. irrigate the colostomy using 30 ml of normal saline c. continue irrigations until no stool is returned d. returns should occur 5-10 min after instilling water

a. dilate the stomach gently with gloved finger rationale: aim of irrigation is for the bowel to be stimulated to contact and then to expel the contents of the last part of the colon

Nurse cares for a client w/a newly applied plaster cast to lower extremity. Should nurses take action? a. elevate leg on pillows and leave cast open to air b. set up a fan to blow on the cast and turn it frequently c. rest casted leg on mattress and avoid handling it until it has dried d. cover cast lightly w/a sheet and remove it frequently

a. elevate leg on pillows and leave cast open to air rationale:Elevation of extremity will prevent edema; elevation on pillows will prevent cast from having contact w/a hard surface that might cause pressure; leaving cast open to air will facilitate drying

the school nurse has a student diagnosed with hepatitis a. it is most important for the nurse to teach the parents of the classmates to observe their children for which symptoms a. fatigue b. increased appetite c. tarry stool d. pallor

a. fatigue rationale: symptoms of hepatitis include fatigue, anorexia, right upper quadrant pain, pruritus, and jaundice children younger than 6 typically do not have symptoms of hepatitis a. older adults will present with jaundice

which risk factors are associated with chronic kidney disease? select all that apply a. hypertension B. DM C. malnutrition d. PVD e. smoking

a. hypertension B. DM

the nurse instructs a pt how to prevent a UTI. which pt statement requires further investigation? select all that apply a. i can go all day without peeing b. i drink 2 liters of fluid a day c. i urinate after sex d. i douche once a week

a. i can go all day without peeing d. i douche once a week rationale: holding your pee in causes bacteria build up. average person pees 6-8 times a day douches can cause infection

the nurse instructs a pt diagnosed with chronic kidney disease about the appropriate diet. the nurse determines teaching is effective if the pt makes which statement a. i love grilling red peppers b. i love pork chops c. i have a cheese sandwich every day d. i eat yogurt for breakfast almost every day

a. i love grilling red peppers rationale: protein, potassium, sodium, and phosphorus are restricted in kidney disease

the nurse instructs a pt taking lansoprazole for the first time. the nurse determines further teaching is required if the pt makes which statement a. i should take the medication on a full stomach b. the capsules are not to be crushed or chewed c. i can take this medication with antacids d. i can open the capsule and sprinkle the contents on soft food

a. i should take the medication on a full stomach rationale: lansoprazole is a proton pump inhibitor and is used for GERD and ulcers; take before meals

the nurse instructs the pt how to prevent calcium calculi. which pt statement indicates teaching is successful a. i will drink 3,000 ml of fluid each day b. i will eat 2 servings of meat or cheese per day c. i will drink at least 2 glasses of cranberry juice daily d. i will eat a large amount of citrus fruits

a. i will drink 3,000 ml of fluid each day rationale: produce dilute urine and decrease risk of kidney stones

which of the following are normal assessments of the renal and urinary systems. select all that apply a. inability to palpate the kidneys b. CVA tenderness upon percussion c. absence of a renal artery bruit d. purulent drainage from urinary meatus e. tympanic sounds over an empty bladder upon percussion

a. inability to palpate the kidneys c. absence of a renal artery bruit

the nurse has a pt with hepatitis. it is most important for the nurse to intervene if the pt makes which statement a. it take acetaminophen when I get a headache b. i have stopped having wine with dinner c. i keep my nails short d. i wash my hands before i eat

a. it take acetaminophen when I get a headache rationale: acetaminophen is contraindicated because it is hepatotoxic. the nurse should instruct the pt avoid otc PT should avoid alcohol, keep hands hydrated, and do hand washing

the nurse understands which is the goal for a diet of patients with chronic kidney disease a. lowered intake of protein due to decreased BUN B. lowered carbs to decrease glucose c. lowered fats to decrease tryglicerides d. lowered amino acids to decrease triglyercides and serum albumin

a. lowered intake of protein due to decreased BUN rationale: pt is at risk for increasing BUN due to inability of kidneys to excrete by products of protein metabolism

the nurse provides care for a pt after a total gastrectomy. the nurse is most concerned with which observation a. ng tube attachee to low continuous suctioning b. urine output 500 ml over 8 hours c. pt asks for pain meds d. pt performs incentive spirometer

a. ng tube attachee to low continuous suctioning rationale: suction should be on low intermittent suction to prevent the ng tube from adhering to the wall of the newly formed pouch or cause trauma to the anastomosis

the nurse recognizes which are risk factors for cholecystitis? select all that apply a. obesity b. male c. female d. african american descent e. european descent

a. obesity c. female e. european descent

immediately after a liver biopsy, the nurse places the pt in which position a. on the right side b. on the left side c. prone. d. supine

a. on the right side rationale: prevent fluid leakage and hemorrhage. ideal position is to lie directly on the liver with ribs pushing the liver. nurse will place a pillow under to hold pressure to insertion site assess aPTT, platelet count, and prothrombin time

the nurse assesses for which finding in a patient with a positive cullen's sign? a. periumbillical bruising b. rebound tenderness c. RUQ pain d. flank bruising

a. periumbillical bruising rationale: acute pancreatitis

after an open cholecystectomy, a pt returned to the unit with an NG tube connected to intermittent suction, a t tube in place, and a penrose drain. what is the purpose of the penrose draine a. remove accumulated bile and blood from the surgical site b. permits irrigation of the peritoneum c. provides access for antibiotic infusion d. creates a route of alimentation

a. remove accumulated bile and blood from the surgical site rationale: following a cholecystectomy, bile and blood can collect in the gall bladder bed and cause increased pain and wound complications. a penrose drain is a flat tube that allows fluid to flow out of the wound bed by gravity

the nurse is caring for an older adult female patient with nocturnal polyuria incorporates which priority nursing diagnosis in the plan of care? a. risk for deficient fluid volume b. risk for sleep deprivation c. risk for excess fluid volume d. risk for urge urinary incontinence

a. risk for deficient fluid volume

which lab result of urine is considered normal? a. specific gravity 1.020, yellow, clear b. specific gravity 1.005, deep orange, clear c. specific gravity 1.035, deep orange, cloudy d. specific gravity 1.001, yellow, cloudy

a. specific gravity 1.020, yellow, clear rationale: normal urine specific gravity is 1.010-1.030

What is a short-term complication to bariatric surgery? a.Pulmonary embolism b. Band slippage c. Malnutrition d. Vitamin deficiency

a.Pulmonary embolism Rationale: Pulmonary embolism, infection, and anastomosis leak

The nurse gives discharge instructions to the family of a patient diagnosed with hepatic encephalopathy. The nurse determines further teaching is necessary if the family makes which of the following statements? a. Our parents should eat meat at every meal b. We should contact doctor if parent is restless at night c. Our parent may have some tremors in hands d. Lactulose may cause bloating and cramps

aOur parents should eat meat at every meal: the pt will be on a low meat diet and high plant protein diet. We should contact doctor if parent is restless at night: client may experience sleep disturbances to lethargy to a deep coma Our parent may have some tremors in hands: asterixis is a sign of hepatic encephalopathy Lactulose may cause bloating and cramps: this is a laxative that promotes excretion of ammonia in the stool

the nurse identifies which daily urinary output as normal for an adult? a. 400 ml b 1500 ml c 720 ml d 3000 ml

b 1500 ml rationale: 400= oliguria caused by dehydration, acute kidney injury, increased ADH secretion 3000= polyuria caused by excessive hydration, DI, DM, or kidney disease

When preparing a patient for peritoneal dialysis, which of the following nursing actions should be taken FIRST? a) Assess for bruit: b) Warm the dialysate c) Position the patient on the left side d) Insert a Foley catheter

b) Warm the dialysate rationale:: should be warmed to body temperature to not disrupt tissue temperature. -A:auscultate the bruit over an AV fistula or AV graft during hemodialysis -C:it depends on where the tube is inserted. Repositioning helps with outflow of dialysate D:do not perform unless there is a proven need; for example if the patient has a full bladder and is not urinating

Which point regarding hepatitis B infection indicates a need for further instruction? a. "It has an incubation period of about 45-60 days" b. "It's route of transmission is fecal-oral" c. "It can be prevented by vaccination" d. "It results in chronic infection"

b. "It's route of transmission is fecal-oral" Rationale: IV drug abuse, perinatal with mother to child Hepatitis A: fecal-oral and shorter incubation

what is the ph of urine a. 3.4 b. 6 c. 8.2 d. 8.5

b. 6 rationale: ph of urine is 4.5-8

Which clinical manifestation detected in the patient with cirrhosis is directly associated with accumulation of ammonia? a. Pruritis b. Altered mental status c. Altered blood pressure & edema d. Petechiae & bleeding

b. Altered mental status Rationale: main sign of hepatic encephalopathy Petechiae and bleeding is vitamin K deficiency with liver problems is priority

Three hours after arriving at the orthopedic unit, a pt complains about a hot feeling under the cast. Which action should nurses take FIRST? a. instruct pt to lie still since cast is newly applied b. Assess circulation in casted extremity and change pt's position c. take pt's temperature and observe for other signs of infection d. medicare pt for pain and notify doctor of complaint

b. Assess circulation in casted extremity and change pt's position rationale:heat is a sign of pressure. Assessing circulation is appropriate bc pressure can limit circulation. Changing position may relieve pressure as well

The nurse cares for a client diagnosed with cholelithiasis. It is MOST important to instruct the client to avoid which of the following foods? SELECT ALL a. Apples B. Brocoli C lettuce d. Cheese e. Bacon f carrots

b. Brocoli: avoid vegetables that cause gas including cabbage, beans and onions d. Cheese: high in cholesterol and fat. Cream, butter, whole milk and icecream should be avoided. Avoid fried foods with high amounts of calories too e. Bacon: bacon and other meats high in fat and cholesterol should be avoided

a pt with type 1 DM is scheduled for a right below the knee amputatation due to a gangrenous toe. the pt asks the nurse why the amputation is so extensive. the nurse responds with which a. a below the knee amputation ensures enough skin to form a flap over the residual limb b. a below the knee amputation results in better circulation and healing c. a below the knee amputation facilitates earliest prothesis training d. a below the knee amputation significantly reduces edema of the residual limb

b. a below the knee amputation results in better circulation and healing rationale: leaving tissues that are poorly supplied with blood would cause poor healing and could lead to the development of additional gangrene

the nurse performs discharge teaching for a pt with a diagnosed with hepatitis B. which precaution is included in the teaching a. burn used paper tissues b. abstain from unprotected sexual intercourse c. use special disinfectant in toilet d. avoid touching family members

b. abstain from unprotected sexual intercourse rationale: hepatitis B is transmitted through blood, saliva, semen, and vaginal intercourse

after inserting a needle into the ventrogluteal muscle to inject vitamin k, which action does the nurse take next a. instruct pt to contract the muscle b. administer vitamin K slowly c. spreads the skin with the thumb and index d. pulls back the needle while injecting slowly

b. administer vitamin K slowly rationale: intramuscular medications should be given slowly for better absorption and decreased pain during the injection skin is spread

The nurse provides care for a pt prescribed bethanechol for urinary retention following surgery. it is most important for the nurse to review the pt history for which condition a. gastric ulcer b. asthma or bronchitis c. HTN d. renal cancer

b. asthma or bronchitis rationale: contraindicated due to bronchoconstriction and increased bronchial secretions

the nurse provides care for a pt with a new colostomy. how should the nurse expect the stoma to appear immediately after surgery a. bluish and dry b. beefy-red and moist c. gray and small d. dark red

b. beefy-red and moist blue indicates necrosis should protrude about 2 cm

the nurse instructs the pt about foods for a high protein diet. the nurse determines teaching is effective if the pt chooses which menu a. taco salad with beef, cheese, crackers, tea b. broiled fish, broccoli and cheese soup, custard c. pb and jelly sandwich, chips and fruit drink d. turkey sandwich, potato salad, milk

b. broiled fish, broccoli and cheese soup, custard

which symptom of liver disease does the nurse expect to see in a pt with leannec cirrhosis? a. cloudy urine b. dark urine c. orange colored stools d. tarry stools

b. dark urine rationale: urine with abnormal bilirubin is mahogany colored and has yellow foam when excreted. cloudy urine is due to high protein in chronic kidney disease or a result of an infection

what is the etiology of glomerulonephritis? a. tubular necrosis caused by bacteria and antibody reactions b. deposition of immunological complexes and complement along the GBM (Glomerulus basement membrane) C. deposition of bacteria components within the loop of henle d. destruction of proteolytic enzymes contained in the GM

b. deposition of immunological complexes and complement along the GBM (Glomerulus basement membrane)

The pt is diagnosed with urinary incontinence. when implementing the plan for urinary habit training, which action does the nurse take first a. provide privacy to toilet b. establish voiding pattern c. assist pt to toilet Q2H D. turn on water faucet when pt is on toilet

b. establish voiding pattern rationale: nurse will keep a record for 3 days of when client voids

the nurse identifies which diet is best for the pt with cirrhosis a. high in fat and low in fiber b. high in protein and low in sodium c. high in calcium and low in fat d. high in iron and low in sodium

b. high in protein and low in sodium rationale: pt will eat a balanced diet selecting foods from all food groups. pt should especially eat protein but avoid salt because it can lead to fluid buildup ascites

an older adult female pt reports stress incontinence. the pt is 5 ft tall, weighs 180, and had 4 vaginal births. which statement by the nurse is most appropriate a. there are very good adult diapers b. lets talk about ways to reduce your weight c. you should drink less water

b. lets talk about ways to reduce your weight rationale: obesity causes stress incontinence pelvic muscle exercises can help this

the most specific lab value in the patient with acute pancreatitis is an elevated in which value? a. bilirubin b. lipase c. trypsin d. lactase

b. lipase

the nurse monitors the pt recovering from hepatitis B. the nurse understands the pt has developed which type of immunity to hepatitis B a. artificial active acquired immunity b. natural active acquired immunity c. innate immunity d. artificial passive acquired immunity

b. natural active acquired immunity rationale: the pt has antibodies to fight the disease

the nurse understands which is the principal reason for the use of enzyme inhibitors (acetazolamide) in a pt with pancreatitis a. pancreatic enzymes are irritating to the liver b. pancreatic enzymes escape into interstitial tissue c. pancreatic enzymes are missing and must be replaced d. pancreatic enzymes are inactivated and must be enhanced

b. pancreatic enzymes escape into interstitial tissue rationale: digestive enzymes, lipase, and amylase escape into the surrounding pancreatic tissues and into peritoneal cavity, causing necrosis. enzyme inhibitors help inactivate the enzymes to minimize the damage

the nurse cares for a pt receiving famotidine. the pt reports smoking and experiencing gastric pain one hour after meals. which response by the nurse is best a. smoking decreases stomach acid production b. smoking interferes with the medications effectiveness, and you are no longer receiving the full anti ulcer effect c. nicotine can increase feelings of anxiety and restlessness, which the medication lowers d. if you smoke too much you will become dizzy

b. smoking interferes with the medications effectiveness, and you are no longer receiving the full anti ulcer effect rationale: pain of gastric ulcer is relieved by vomiting

the nurse instructs the pt how to increase folic acid. which food contains folic acid a. oatmeal b. spinach salad c. grapes, apples, bananas d. chicken

b. spinach salad other folic acid foods are organ meats, broccoli, legumes, asparagus, milk and orange juice

the nurse provides care for an older adult pt 8 days after an open reduction of the hip. the nurse intervenes if which observation is made a. the pt ate half of the food b. the pt is not wearing elastic stockings c. the pt requires assistance to transfer from bed to commode d. the pt requires pain medication 3 times per day

b. the pt is not wearing elastic stockings rationale: DVT is the most common complication after hip surgery. wear stockings or sequential compression device to prevent this. encourage fluids

the nurse in the outpatient clinic counsels the pt with a diagnosis of cholecystitis. the nurse determines teaching is successful if the pt makes which statement a. i like a lot of cream on my oatmeal b. we eat a lot of broiled fish and chicken c. i can't wait to eat the chocolates my children gave me d. my favorite dish is broccoli with cheese sauce

b. we eat a lot of broiled fish and chicken rationale: broiled lean meats are high in protein and low in fat. the pt should avoid meats fried or have high fat content, including high dairy. cooked fruits, non gas forming vegetables , bread and cereal is allowed

Which of the following urine outputs BEST indicates to the nurse that a patient's kidneys are functioning normally? a) 555 mL in 2 hr b) 30 mL in one hr c) 1,500 mL in 24 hr d) 800 mL in 24 hr

c) 1,500 mL in 24 hr RATIONALE: normal urine output is 800-2000 ml in a 24 hour period with an intake of about 2 liters a) 555 mL in 2 hr: polyuria is an indication of infection, diabetes, kidney failure or kidney stones b) 30 mL in one hr: this may indicate kidney failure or an obstruction d) 800 mL in 24 hr: this would be minimum urine output unless there is an obstruction or kidney failure

Nurse cares for a client in balanced suspension traction. Client reports pain in affected extremity, and the nurse administers prescribed medication. One hour later the client states, "I don't know why, but pain isn't getting any better." Which action does a nurse take first? a. contact doctor b. offer pt a backrub c, perform a neuromuscular assessment d. assess pt level of pain

c, perform a neuromuscular assessment rationale:an early sign of acute compartment syndrome is sudden inability of pain medication to relieve pain. Compartment syndrome is caused by pressure buildup from internal bleeding or swelling of tissues contacts health care provider: nurse will assess pt before calling doctor offers client a back rub: appropriate but nurse should assess the cause of pain before this assesses level of client's pain: nurse will perform neurovascular assessment to determine the cause of unrelieved pain

the nurse reviews the labs for a pt with leannec cirrhosis. the nurse expects to find which lab value a. albumin 4.0 b. AST, SGOT 38 c. ALT, SGPT 600 d. LDH 150

c. ALT, SGPT 600 rationale: normal levels are 5-35

Which cirrhosis complication is most likely caused by the accumulation of ammonia and toxins in the blood? a. Ascites b. Portal hypertension and varices c. Hepatic encephalopathy d. Hepatorenal syndrome

c. Hepatic encephalopathy Rationale: ammonia isnt being converted to urea so it is building up in the body

The nurse is caring for a client diagnosed with peptic ulcer disease. Which assessment data would cause the client to require an immediate intervention by the nurse? a. The patient's hematocrit is 40% b. The patient's output is 480ml for a 12 hour shift c. The patient has coffee-ground emesis d. The patient has T 98.6, HR 98, RR 20 and BP 102/78

c. The patient has coffee-ground emesis Rationale: normal urine output is 30 ml/ hour Coffee ground emesis indicates blood

the nurse recognizes that genetic counseling is appropriate for which patient a. children with frequent UTIs b. adult with frequent UTIs c. adult with autosomal-dominant polycystic kidney disease d. adult with metastatic renal cancer

c. adult with autosomal-dominant polycystic kidney disease

the nurse instructs the pt how to care for their ostomy stoma. which is the correct method of this a. drape area and wash with hexachlorophene soap b. clean stoma vigorously with alcohol wipes and pat dry c. clean around stoma with soap and water and pat dry d. drape the area and cleanse the stomach with iodine

c. clean around stoma with soap and water and pat dry avoid soaps with oil or perfurme

the home health care nurse visits a pt with ulcerative colitis. the pt reports perineal irritation due to frequent stools. which suggestion by the nurse is best a. apply a heat lamp to the perineal area 3 times per day b. use protective plastic bed pads c. clean the perineal area with soap and water after each bowel movement d. increase roughage in the diet to prevent frequent stools

c. clean the perineal area with soap and water after each bowel movement rationale: cleaning the area keeps the skin free of stool and decreases irritations. the nurse can suggest the use of sits baths. the pt may apply petroleum jelly to the area to sooth irritated skin

a pt is diagnosed with a duodenal ulcer. the nurse understands the most common reason for insertion of an NG tube post includes which a. take samples of gastric acid b. assess stomach for bleeding c. decompress the stomach d. permit saline irrigation

c. decompress the stomach

An elderly client undergoes an open reduction and internal fixation of left femoral head after a fracture. Which action by a nurse is best? a. offer client a clear liquid die b. turn pt to unoperated side c. encourage pt to cough and deep breath every 2 hours d. instruct pt to exercise arms

c. encourage pt to cough and deep breath every 2 hours rationale: respiratory complications can be prevented by coughing and deep breathing at least every 2 hours

a pt is scheduled to have an intravenous pyelogram (IVP). which information is most important for the nurse to obtain prior to the procedure? a. date of last ECG B. Time of last meal c. history of allergies d. response to emetics

c. history of allergies rationale: iodine, shellfish and other seafood IVP is an X-ray of kidneys, ureters, and bladders. PT is NPO after midnight and should have completed a bowel prep. emetics will not be administered during an IVP

when the pt is in the diuretic phase if AKI, the nurse must monitor which electrolytes a. hypokalemia and hyponatremia b. hypokalemia and hypernatremia c. hyperkalemia and hyponatremia d. hyperkalemia and hypernatremia

c. hyperkalemia and hyponatremia

the nurse assesses a pt with ulcerative colitis. the nurse expects the pt to make which statement? a. i feel a constant sharp pain in my lower abdomen b. i feel an intermittent gnawing pain in my middle abdomen c. i feel an intermittent cramping pain in my lower abdomen d. i feel a burning pain in my upper esophagus after i eat

c. i feel an intermittent cramping pain in my lower abdomen rationale: pain occurs prior to defecation. nurse should obtain a diet history and assess for bowel sounds and areas of tenderness acid reflux and gastritis will cause a burning pain that is severe after eating

the nurse obtains a history from a pt with cirrhosis. which stamement does the nurse recognize as most directly related to the pt's development of cirrhosis? a. for the past several weeks i have not slept much b. since my spouse left me, i have been eating terribly c. i have been drinking a fifth of alcohol a day for the past few years d. my spouse is a very heavy smoker

c. i have been drinking a fifth of alcohol a day for the past few years rationale: most common cause of cirrhosis is chronic hepatitis c infection and alcohol induced liver disease s/s of cirrhosis are nausea, vomiting, anorexia, weight loss, fatigue, headache, ascites, jaundice, and spider angiomas

the nurse instructs a pt how to increase calories in the diet. the nurse determines teaching is effective if the pt makes which statement a. i will broil all my meats b. i will eat bread at all meals c. i will snack frequently on nuts and dried fruits d. i use low fat dressing

c. i will snack frequently on nuts and dried fruits

prior to the patient's CT scan, which information should be obtained from the patient a. a family history of CT scans b. time of patients last meal c. list of patients allergies d. time of last pain medication

c. list of patients allergies

the nurse provides care for a pt with acute cholecystitis. the pt says "my stomach hurts all the way up to my right shoulder. i am experiencing n/v." which does the nurse carry out first a. insert NGT tube b. trimethobenzamide rectally c. morphine q4h prn d. NPO

c. morphine q4h prn RATIONALE: first address pain. then place pt on NPO then place pt on antiemetic

as part of pre op teaching for bowel surgery, the nurse teaches the pt about foods that are allowed on a low residual diet. which menus can the pt choose? select all that apply a. bouillon soup, grilled cheese, grape b. corned beef, buttered peas, custard c. roast lamb, buttered rice, sponge cake d. bacon and tomato sandwich, sugar cookie e. scrambled eggs, whole wheat toast, prune juice f. baked chicken, mashed potatoes, and canned peaches

c. roast lamb, buttered rice, sponge cake f. baked chicken, mashed potatoes, and canned peaches rationale: low residual diet includes well cooked tender meats, fish and poultry. milk and mild cheese, juice without pulp, canned fruits, riped bananas, white bread or refined bread, potatoes without skin no fiber

the nurse provides care after a traditional open cholecystectomy. it is most important for the nurse to position the pt in which position a. side lying with bed flat b. supine c. semi fowlers d. lying flat with knees elevated

c. semi fowlers rationale: allows optimal breathing to prevent pneumonia and will place less stress on suture line

the nurse provides care for a pt immediately following a right below the knee amputation. the nurse is most concerned if which observation is made a. the pt periodically naps b. the pt reports a throbbing headache c. the pt reports persistent pain at the operative site d. the pt voices concerns about a prosthesis

c. the pt reports persistent pain at the operative site rationale: redness, swelling, and pain indicate inflammation and possible infection. the nurse should inspect the limb and drainage, administer prescribed analgesic and notify the doctor

a pt has a cast removed after a broken tibia. which action does the nurse identify is contraindicates for care of the extremity after the cast is removed a. provide support for the extremity after cast removal b. gently wash the extremity's skin to remove dried, scaling skin c. vigorously massage extremity's skin to restore circulation d. apply emollient lotion to extremity's skin to soothe dry skin

c. vigorously massage extremity's skin to restore circulation rationale: vigorously massaging may cause the skin to breakdown due to the skin;s dry condition and may release a thrombus. a pt is at risk for forming while wearing a cast because the blood flow the veins is slower due to immobility. symptoms of thrombus include re,d warm skin as well as swelling and pain

Which finding in the urine of the client diagnosed with chronic kidney disease is expected by the nurse? a) Hematuria b) Polyuria c) Dysuria d) Oliguria

d) Oliguria RATIONALE: urine production less than 400 ml a day is a sign of kidney failure A: caused by glomerulonephritis C: : this would be s/s of uti

The client with alcoholic cirrhosis is at great risk to develop which complication? a. hepatitis b b. pancreatic cancer. c weight gain d epistaxis

d. Epistaxis rationale : acute hemorrhage from the nostril, nasal cavity, or nasopharynx. Bleeding is a common risk factor of cirrhosis due to decreased formation of coagulation studies Hepatitis b: cause of cirrhosis Pancreatic cancer: chronic alcohol consumption can lead to pancreatitis Weight gain: weight loss is common. Ascites may mask weight loss appearance

the nurse cares for the client with crohn's disease. Which finding describes a common complication of crohn's disease? a. Reflux esophagitis b. Chronic constipation c. Hypothermia d. fistulas

d. Fistulas: abnormal tracts between 2 or more body areas in GI tract, skin, bladder or vagina Reflux esophagitis: this is GERD Chronic constipation: frequent diarrhea is seen due to bile salt malabsorption Hypothermia: more common with bacterial infections

A patient reports tarry stools and emesis with a "coffee grounds" appearance. They have a history of peptic ulcer disease. Which complication is the patient likely experiencing? a. Perforation b. Penetration c. Obstruction d. Gastrointestinal (GI) bleeding

d. Gastrointestinal (GI) bleeding

A nurse witnesses a car hit a pedestrian in a parking lot. As the nurse approaches the pedestrian, the pedestrian cries out, "I think my leg is broken!" Which action does a nurse take first? aasks client to move ankle and foot on affected side b. Tell pt to lie still and remain calm c. Immobilize affected leg d. Inspect leg for signs of bleeding

d. Inspect leg for signs of bleeding rationale:nurse should first expose extremity for signs of bleeding, swelling or any deformity. -asks client to move ankle and foot on affected side: nurse should assess motor function by asking pt to move affected leg distal to fracture -Tell pt to lie still and remain calm:: this is true but not a priority and pt may not be able to stay still due to pain -Immobilize affected leg: the first step is inspection although immobilization is important

the nurse correlates which clinical manifestation with cholecystitis? a. retroperitoneal pain b. absence of bowel sounds c. diarrhea d. RUQ pain

d. RUQ pain

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? a. Riboflavin deficiency b. Folic acid deficiency c. Vitamin A deficiency d. Vitamin K deficiency

d. Vitamin K deficiency Rationale: vitamin K deficiency with liver problems

the nurse expects which lab value for the pt with ulcerative colitis? a. RBC 4 million b. platelet count 75,000 c. HgB 18.2 d. WBC 15,000

d. WBC 15,000 RATIONALE: due to inflammation, WBCs and erthyrocyte sedimentation rate will be elevated. normal WBC for adults is 4,500-11,000. sodium, potassium, and chloride levels may be decreased due to frequent diarrhea RBC and platelet are not affected HgB may be decreased

Nurse cares for a client in Buck's traction. It is most important for nurses to take which action? a. encourage client to limit body movements b. remove weights immediately when client reports discomfort c. give pain medication regularly d. allow weights to hang freely at all times

d. allow weights to hang freely at all times rationale: weight should hang freely, not touching the bed or floor as to not compromise the traction system encourage client to limit body movements: able to move in bed as tolerated while maintaining the leg in proper alignment remove weights immediately when client reports discomfort: weights are not removed unless there is a prescription give pain medication regularly: nurse may give alagesis, anti inflammatory or muscle relaxants

the nurse notes an older adult pt is suddenly disoriented to person, place, time, and is falling. which action does the nurse take first a. obtain a vest restraint b. frequently orients the pt to person, place, time c. instruct pt to call before ambulating d. assess for s/s of UTI

d. assess for s/s of UTI

which diagnostic study is most specific in identifying PKD a. abdominal xray b. creatinine level c. urinalysis d. computed tomography scan (CT scan)

d. computed tomography scan (CT scan)

During peritoneal dialysis, a patient suddenly begins to breathe more rapidly. Which of the following actions should the nurse take FIRST? a. discontinue dialysis b. check the VS C. notify the doctor d. elevate HOB

d. elevate HOB Rationale: elevating the HOB will decrease pressure of the diaylsate on the diaphragm and increase the vital capacity of the lungs. draining the cavity of fluid will further decrease the pressure VS are recorded Q15 min during first few exchanges of dialysis

The nurse teaches a client with a below the knee amputation to care for the residual limb at home. the nurse advises the client to take which action a. apply cream daily to the residual limb b. cover residual limb w/a nylon sock c. keep residual limb elevated d. expose residual limb to air

d. expose residual limb to air rationale: exposure to air facilitates healing of the limb. It is important for the skin of the limb to be healed and dry in order to be fitted for the prosthesis apply cream daily to the residual limb: gently wash and dry the residual limb. Avoid putting creams or lotions on skin cover residual limb w/a nylon sock: limb sock is made of cotton which absorbs perspiration and prevents direct contact, pt should change sock daily keep residual limb elevated: elevating the limb will cause contractures

which is a pre renal cause of acute kidney injury a. acute glomerulnephritis b. septic shock and nephrotoxic injury c. calculi formation d. hypovolemia and myocardial infarction

d. hypovolemia and myocardial infarction

the home health nurse makes a visit to a pt receiving enteral feeding through a gastronomy tube. the pt adult caregiver reports the pt has frequent loose stools. which statement made by the adult caregiver needs further investigation by the nurse a. i give 240 ml of formula for over one hour b. i refrigerate unused formula c. i hang a new bag and tubing every 24 hours d. i am able to give liquid medicines through the tube

d. i am able to give liquid medicines through the tube rationale: many liquid meds contain sorbitol which can cause osmotic diarrhea for some clients. the nurse needs to determine what meds the pt is receiving and if it the meds contain sorbitol intermittent tube feedings should be given 4-6 hours per day. feedings can be administered by gravity over 30-60 minutes. this amount is not excessive for a tube feeding. unused formula can be refridergated. boluses of cold formula can cause diarrhea hang new tubing every 24 hours

the nurse teaches a pt with a fractured left femur that is in a cast. the pt asks how to keep the muscles of the legs strong during the time the cast is on the left leg. which response by the nurse is best a. it is important to perform active ROM everyday b. ill teach your parent to perform active assitnitve ROM c. perform leg lifts with a 2 lb weight attached to your ankle d. ill teach you how to do isometric exercises with your left leg

d. ill teach you how to do isometric exercises with your left leg rationalE: isometric exercises are contractions of a muscle

To prepare a client for a paracentesis, it is essential for the nurse to take which action? a. administer an enema b. premeditate with narcotic c. restrict intake of fluids d. instruct pt to empty bladder

d. instruct pt to empty bladder rationale:a needle or catheter will be inserted into the peritoneal cavity to obtain ascitic fluid. The pt is at risk for a bladder injury by the procedure if the bladder is not empty and small Administer an enema: this is not necessary Premedicate pt with a narcotic: not required, but nurse will monitor pt for shock Restrict intake of fluids: not necessary. Fluid and salt may be decreased due to underlying ascites

the nurse is caring for an older adult with intermittent urinary incontinence. the nurse recognizes that the incontinence is a result of which structure failing to contract to keep urine in the bladder until micturition? a. detrusor muscle b. external urethral sphincter c. urethra d. internal urethral sphincter

d. internal urethral sphincter

a nurse cares for a pt after an ileostomy procedure. which action does the nurse take first a. empty collection bag every hour b. apply lotion to skin c. cover stoma with 3 layers of gauze d. measure output and document

d. measure output and document rationale: output will be liquid emptied when 1/2 full avoid lotions

the nurse should question which medication in the pt with cholecystitis? a. acetaminophen b. demerol c. ibuprofen d. morphine

d. morphine

a pt is diagnosed with chronic kidney disease. which finding is expected by the nurse? a. hematuria b. polyuria c. dysuria d. oliguria

d. oliguria rationale: less than 400 ml per day hematuria caused by glomerulonephritis

a pt with a hx of kidney disease is reporting weakness and lethargy. the pt's ECG shows sinus bradycardia with a prolonged PR interval. which lab value does the nurse expect to find a. potassium 3.0 b. potassium 3.5 c. potassium 5.0 d. potassium 8.5

d. potassium 8.5 rationale: s/s of hyperkalemia include muscle weakness, paralysis, nausea, diarrhea, and dysrhythmias

the nurse provides care for a pt after an amputation with an immediate prosthetic fitting. the nurse includes which activity in the pt's plan of care a. assess drainage b. observe dressing for excessive bleeding c. elevate the residual limb for no less than 48 hours d. provide cast care on the affected extremity

d. provide cast care on the affected extremity rationale: immediate prosthetic fitting requires the application of a plaster cast to form a total contact socket for seating a temporary prosthetic limb

the nurse understands which factor is most likely the source of hepatitis D a. eating infected shellfish b. overly exerting onself c. poor hygeine d. receiving a blood transfusion

d. receiving a blood transfusion rationale: hepatitis D co-infects with hepatitis B. it is spread by contact with infected blood and or body fluids infected shellfish can cause hepatitis a

the nurse provides pre-op teaching to a pt scheduled for a colostomy. the nurse explains that 24 hours after surgery the colostomy drainage will look like what? a. large amount of dark bloody output b. large amount of liquid stool c. formed stool with watery drainage d. scant amount of bright bloody drainage

d. scant amount of bright bloody drainage rationale: the colostomy will begin draining liquid stool 2 to 4 days after surgery

the nurse provides care for a pt with an NGT. the pt reports discomfort in the back of the throat. which action by the nurse is best a. move the tube out 2 inches b. change diet to full liquid c. reinsert tube into other nostrol d. spray with viscous lidocaine solution

d. spray with viscous lidocaine solution rationale: local anesthetic to relieve discomfort

a pt is given hepatitis B immune globulin after having unprotected sex with a person with hepatitis b for which reason? a. prevent other STIs b. stimulate immune system to develop antibodies to hepatitis c. prevent pt from contracting hepatitis d. temporarily increase the pt resistance to hepatitis

d. temporarily increase the pt resistance to hepatitis rationale: HBIg provides short lived protection against HBV. example of passive acquired immunity

the nurse cares for an elderly pt admitted with hepatitis a. the pt is anorexic, reports weakness, incontinent of urine, and involuntary of stool. the nurse determines that care is appropriate if which observation is made a. staff caring for the pt follows standard precautions b. pt is offered more frequent feeding during afternoon and evening hours c. the nurse maintains the pt on strict bedrest d. the nurse places the pt on contact precautions

d. the nurse places the pt on contact precautions rationale: hepatitis a is spread fecal oral route; contact is required due to fecal incontinence. instruct pt of good hand washing offer diet high in calories, alternate periods of rest and activity especially important for elderly

a pt diagnosed with chronic kidney disease is prescribed a low protein diet. the nurse understands this diet is prescribed for which reason a. to decrease fluid retention b. to increase diaphoresis c. to prevent hypovolemic shock d. to preserve renal function

d. to preserve renal function rationale: low protein diet leads to favorable metabolic effects and can save kidney function